A clean bill

Beneath the bright lights of big cities around the world, not all is so alluring. Urbanisation may be the desirable result of the benefits of city living, but conurbations also bring the negative consequence of intense concentrations of illness and death.

With globalised travel, infections are able to move across borders more quickly and effectively than ever. Non-communicable diseases are also spreading as wealth rises, bringing pollution, traffic accidents, mental health problems and lifestyle ailments such as diabetes intensified by less physical exercise and unhealthy diets.

IN Urban Ingenuity

As David Wilson, global HIV/Aids programme director of the World Bank, noted at a pioneering City Health conference in London in October that already more than half of the globe’s total population is urban. By 2025, there will be more than 600 cities, each with more than 1m inhabitants; and the majority of the poorest people on Earth will be living in urban areas. “Cities concentrate and incubate new health threats,” he says.

Londoners may overall have relatively high average income and longevity. Yet that conceals impoverished pockets of people with far worse health outcomes, harbouring some of the highest rates of tuberculosis infection in western Europe, for instance. Immigrants, who are essential for urban growth, get a particularly poor deal from prevention and treatment programmes.

The City of London itself has exceptional challenges in coping with an enormous transitory population of workers and evening visitors far outstripping permanent residents.

That suggests the need for innovative approaches to bring convenient healthcare services to people wherever they spend time and not just where they live.

As elsewhere in the UK and beyond, that also means finding new ways to cope with the corollary of the superficially attractive and wealth-generating urban entertainment “eco-system” of pubs and clubs: a thoroughly mixed cocktail of drug abuse, alcoholism and violence.

This year’s laureates in the award for urban healthcare innovation highlight both the pressures of living in built-up areas around the world, and the continued ability of residents, social organisations and the private sector to work together to generate new solutions, even when public sector support is limited.

China and India are the world’s most populous nations, with a large and growing number of its biggest cities. New migrants are essential to maintain that dynamism but are among the most precarious, disorientated and disenfranchised inhabitants. Many live in marginal areas with poor infrastructure and suffer disproportionately bad health.

Yet they are sources of ideas and energy, as GSK’s winning New Citizen Health Care Project in Shanghai, and the runner up, the Child Eye Care Charitable Trust in Mumbai, demonstrate. Empowering people to improve their own lives and function as a community to help others can deliver powerful results.

Similar innovation is taking place in urban locations worldwide. Many may think of Latin American cities as chaotic and crime-ridden, none more so than Medellín in Colombia, with its association with the country’s notorious drug cartels.

Yet local civic leaders have transformed the environment through urban planning, enhanced public transport, the provision of libraries, bike lanes and car-free zones.

As John Ashton at Liverpool Medical School put it at London’s City Health conference, citing a long tradition of urban renewal, planning, community involvement and innovation over decades: “The city can be such a powerful focus for health protection and improvement, as a total place where all can come together round the table to work for the common wealth and common good.”

Edinburgh’s politicians earlier this year took a stand against granting licences to sell alcohol to supermarket outlets. It has become the subject of a legal challenge; but it is a pioneering effort to limit cheap supplies that intensify local health problems.

Their counterparts in Vancouver have defended the provision of a supervised site for drug users, designed to respond to a reality rather than stigmatising a practice that would otherwise operate underground. The result has been to help rehabilitate the deprived Downtown Eastside district.

The Stad initiative – Stockholm Prevents Alcohol and Drug Problems – has shown progress through a combination of tough enforcement of sales, community education and training of doormen and serving staff. The results far outweigh the costs.

In future urban innovation award applications, it would be worthwhile highlighting and crediting such initiatives that come from elected officials and civil servants working alongside the non-profit and private sectors. It would also be useful to provide rigorous analysis demonstrating efficacy, and highlighting lessons for others seeking to replicate the best approaches.

Urban areas in long-industrialised countries provide a taste of things to come in the best and the worst of global health trends. Yet the use of new technology including mobile phones gives poorer countries the chance to leapfrog their richer peers in developing innovative approaches. Innovation can come from anywhere. And in the struggle against the escalating epidemic of non-communicable diseases, humanity needs inspiration from everywhere.

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